The Psychology of the ObamaCare Debate

“How can the government make us buy health insurance?  What gives them that right?”

Sitting on my left while our airplane raced above the clouds, Elizabeth was clearly upset about Obamacare.  She wondered why the bill had to be so long, and why Obama would endorse a plan that doubled her health insurance costs.  But nothing vexed her more than the individual mandate.

At least that’s what I though until I spoke with her at greater length, and she revealed a profound truth to me about people’s attitudes towards the mandate and towards Obamacare more generally: she showed me that deep down she liked the idea of the mandate, once she realized its important role in accomplishing goals people on all sides of the political spectrum care about deeply.

We were flying towards North Carolina the day before the Supreme Court held its oral arguments on Obama’s healthcare plan.  Elizabeth had heard a great deal about the mandate.  She read The Wall Street Journal regularly, in part because it was so relevant to her work in banking.  And she enjoyed watching Bill O’Reilly on Fox News, but not Hannity, who she thought was “too extreme”.  She was by no means a conservative extremist.  She had major concerns about the banking industry for example, and as a Christian felt strongly that income inequality is a moral problem that neither party was addressing in an effective manner.  But she was solidly Republican, no doubt about that, and she agreed with most people in that political party that Obamacare was hurting the economy.  And above all she believed the health insurance mandate was “un-American.”

Elizabeth and I began discussing Obamacare because she saw me reading a medical journal and wondered what I, as a physician, thought of the law.  I told her that I teach an undergraduate course at Duke on healthcare policy, and that I was quite familiar with this big and complex piece of legislation, which I saw as having strengths and weaknesses almost inevitable in such a complicated law.

That got her going on how long the bill was, and she wondered why it had to be so complex.

“Well let’s just look at one part of the bill,” I said to her professorially.  “The bill aims to provide financial subsidies to help people buy insurance, who otherwise might not be able to afford it.  That means the authors of the bill had to put together a list of how much they would subsidize people, depending on how much money they made and the size of their family.  Just laying out the details of that subsidy takes a lot of words.”

“But if it’s so long,” Elizabeth wondered, “how is anybody going to be able to read it before they vote?  I think there should be a law requiring legislators to only vote on bills they’ve read, cover to cover.”

I didn’t ask her how long that kind of bill would have to be.  Instead, I explained that legislation would come to a halt under that rule—that legislators don’t have time to pour over every word of every bill they vote on, but have staff that help them understand details, and tend to focus on bills that are in their expertise.  I explained that a Congressperson who specialized in, say, health insurance regulation would have paid a lot of attention to this bill while relying on his colleagues to let him know what is going on in, for example, upcoming agricultural legislation.

She was deeply unsatisfied.

Then she complained about how Obamacare would double the cost of her health insurance.  I asked her where she had heard that and why she thinks it would happen.  “I’ve read a lot of analyses of the law, and none predict anything like that kind of price escalation,” I told her.  “And why would the Democrats have passed a bill that would hurt people this much?”

She remained unconvinced.

She was equally unconvinced about all my arguments in favor of the health insurance mandate.  I explained the difference between broccoli and health insurance for example, but she remained worried that the government would control her supermarket behavior.  I discussed the free rider problem—how hospitals are required to offer emergency care to patients and thus pay for their care if they can’t afford it on their own and lack insurance to cover the costs.  Indeed, this free rider problem was the main reason that the conservative Heritage Foundation supported an individual mandate as far back as the 1990s.

On a 0-100 persuasion scale, I was scoring something like a -11.

Until Elizabeth told me the one thing she was willing to admit she liked about Obamacare: “I like that it won’t let insurance companies deny care to people with pre-existing conditions.”

At last: common ground!

In the Supreme Court oral arguments, the Obama administration contended that if the individual mandate is struck down as unconstitutional, then the court does not need to throw out the whole law.  But it did believe that the court would need to get rid of Elizabeth’s favorite rule—the ban on pre-existing conditions.  The reason for their argument was that insurance companies, if required to take everyone who comes to them as client regardless of their health, would go bankrupt because so many people would simply wait until they became sick before purchasing health insurance.  That means insurance companies that charge reasonable premiums will find themselves deluged by customers who cost a lot more than the average cost of their premium.  That’s what health economists call “adverse selection.”

In other words, if you like the idea of letting everybody get insurance, even if they through no fault of their own carry a diagnosis of breast cancer, then you want to make sure everybody gets health insurance.  Because if you don’t, insurance companies will have only two choices: first, they can jack premiums up to cover the expense of all the sick people coming their way.  Or they can go out of business.  Private health insurance can’t be affordable if we force insurance companies to take all comers, unless we find some other way to make sure everyone comes to them, whether they’re sick or healthy.

The Obama team made a mistake in not marketing the mandate as being an inevitable part of its efforts to stop insurers from either denying coverage to people with pre-existing conditions, or charging premiums that are beyond anybody’s reach.  Fortunately, it is not too late.  Justice Kennedy, likely the deciding vote on the Supreme Court, knows that striking down the mandate would be a disastrous thing to do if we leave legislation intact to force insurance companies to take all comers, regardless of pre-existing health.  He also knows that striking down the ban on pre-existing conditions—the most popular part of Obamacare—won’t reflect too well in the court of public opinion.

Perhaps an upholding of the individual mandate will be the first step towards public acceptance of Obamacare.  Maybe in reconciling themselves to the Supreme Court’s opinion, the Elizabeths of the world will realize that at least a few pages of the Affordable Care Act made a bit of sense.

Peter Ubel is a physician, behavioral scientist and author of Pricing Life: Why It’s Time for Health Care Rationing and Free Market Madness. He teaches business and public policy at Duke University. Peter’s new book, Critical Decisions will be available in the fall of 2012. You can follow him on his personal blog.

34 replies »

  1. Interesting that a physician would have “common ground” with a statment like Elizabeth’s that “I like that it won’t let insurance companies deny care to people with pre-existing conditions.”

    I’ve never heard a physician accept that insurers provide “care”, which they do not. They indemnify the costs incurred in receiving care.

    It’s also impossible to believe that it takes all the bureaucracies erected by Obamacare to figure out how much to subsidize low-income patients. Just calculate a refundable tax credit and give it to them.

  2. Seniors on medicare must pay a 1% penalty for each month that they wait to enroll in a prescription plan if they elect not to take it when they are eligible. I don’t remember anyone in either political party challenging that a few years back.

  3. No, because I do not embrace your point of view, you vilify me with associating me with a horrendous discriminator, which is the exact rhetoric of current extremist political partisan dividers. You reveal your mentality by not only associating me with a pure villain, but you compare yourself with Mother Teresa. Truly insulting and over inflating your opinion.

    I’m not interested in an apology nor toning down further comments, good luck saving the world with your infinite resources to see your vision realized. And those reading this banter here, watch out tolerating the over tolerance of the left/Democrats/liberals. They easily attract the nefarious elements who take advantage of this blind loyalty to embrace all, irregardless of goals and choices. Trust is earned, not just granted.

    And believe me, good doctors who I saw as mentors believed and practiced with some caution. Especially allowing non physicians to dictate health care policy while ignoring physician input.

    Gee, sort of what PPACA is doing?!

  4. You think some people do not deserve to live. It is not extreme but rather obvious and logical to recognize the similarity of that attitude with Hitler’s. You do not think logically and have a severe lack of ability to feel compassion for your fellow man. Those are more things you have in common with Hitler. Your way of thinking is what is off base, not the comparison of its similarities to other sociopaths.

  5. associating someone with hitler is not an extreme interpretation?

    Nice rationalizing with that comment. Gotta love the overtolerance attitude of people, we HAVE to treat everyone indefinitely, because, hey, to this crowd, we have taken a vow of poverty and must give everyone what they want.

    And you wonder why health care is floundering with this kind of expectation. Sorry, not everyone gets full court presses all the time. That is reality. We are not in OZ!

    And by the way, the REST of the world thinks our health care system is nuts? Doubtful everyone else outside our borders embraces that attitude. But, liberal thinking wants to promote that agenda.

    I really believe there will be some liberals/Democrats who will lose it should the Court declare PPACA void. Just like we will see Republicans lose it once we pull out of Afghanistan. Scary this is what composes alleged leadership in this country. Now that I would agree the rest of the world thinks is nuts: our political system

  6. I did not make an extreme interpretation. You took an extreme position. Adolf definitely would be on your side. Teresa would be on mine. Did you never learn the Golden Rule? It is a basic tenet of common human decency (something some people refer to as “morality”), My Friend. Yes, when it comes to health care I absolutely believe everyone should be treated equally according to medical science (no matter how weak or stupid they may be) and not discriminated against because of who or what they are. This is the basic rule of law in every other civilized nation on Earth except ours, at half and less the cost we spend to ration one out of every four Americans trapped in our private profit-driven health unsurance non-system (with no way out) to zero with wait times until after it’s too late. We even helped the Iraqis write into their new constitution the guaranteed right of equal health care protection for all under the law. We on the contrary win all the booby prizes for health care discrimination, rationing, injustice and wait times, plus win the grand booby prize for our basic inhumanity towards our fellow man. Do you think police should protect some but not all? How about firemen? Protect rich-enough people’s homes but let Shantytown burn? Should teachers teach some but not all? Maybe some of us should have access to drive on our roads, while others, not so much? You don’t seem to understand that we are all in this together whether you like it or not. Imagine a teacher looking parents in the eye and explaining he or she will not teach their child because the child is just too slow, or the parents don’t have enough money. Imagine the society we all would live in if 25% of our children trapped in such a system had to go without equal access to education for all. The rest of the world thinks our health care system is nuts, and I agree. They just can’t understand why we just can’t understand. I can’t either.

  7. OK, glad you took that extreme interpretation. I have no issue with people who are dealing with illness that they inherited or unintentionally obtained by trauma or other uncontrolled contact. What I find disturbing are comments I interpret from yours above that we should treat EVERYONE equally and without hesitation because they are simply human. Sorry, don’t agree, and find this overtolerance and complete equality for all as equally as devastating as the intolerance of fascism and other tyrant regimes.

    And by the way, agree with your Oz comment, except it is the Democrats who are behind the curtain, and this failed legislation will only provide responsible and invested Americans with pieces of useless paper, broken clocks, and meaningless testimonials. And we have too many citizens who cluelessly smile when presented with trite tokens that allow the real scam artists to smile and go unnoticed. Both parties!

    You all think that all doctors will treat every single person as a complete and deserving person from moment one to their last moment. When you find you are being scammed or just used, yeah, good luck ignoring that is the agenda of your “patient”. Glad all those colleagues out there blindly supporting this legislation signed that contract!

    Ok, let’s finish with this perspective: go with Ryan’s budget of screw the masses and protect his cronies, or, go with, wait, what budget has any Democrat proposed that has some legitimate traction, not Obama’s that was rejected by 97-0 in the Senate a month or so ago, so we’ll go with their last 2 years as a majority and their raising the debt to about 11 trillion before the House went Red. Be screwed overtly, or covertly? Wow, that is some choice, but partisans here don’t care.

  8. see that the link did not work right per the presentation of the piece, so here is the quote near the end I referred to:

    “liberals control unions and most of academia and the media. Yet such is their evident lack of confidence in their powers of persuasion they are desperate to control the speech of others.”

    Hope that clarifies.

  9. “Of all forms of injustice, discrimination in health care is by far the most cruel and inhumane”….Dr. Martin Luther King.

  10. Wow. You and Adolf would have gotten along great. I have an inherited auto-immune disease. My mistake was choosing the wrong parents. And we prefer to pay to amputate legs, destroy eyesight and kidneys (for just a few examples) rather than pay for preventative treatment. Not everybody dies as fast as you might prefer for them to. And I’ve paid through my nose my entire life while I was young and healthy to help take care of older, sicker people. That’s why (as it was explained to me) my health insurance premiums were through the roof even though I never needed or used it. That’s why I was told by Ronald Reagan in 1982 that my Social Security taxes would be increased by 125% during almost my entire working life (because, as he explained it, Baby Boomers would have to be the first generation to not only pay for the two generations before them, but to also PRE-pay for their own benefits). NOW you want to change THAT? I wish I had more time to try to explain the truth to you, but I don’t. For now I truly hope you are not really an MD, because I think you need to see the wizard for a heart and a brain.

  11. bspoon writes above, “I also believe that if we were all united together into the same transparent, non-discriminatory, not-for-profit public plan, in the light of day we would save millions of unnecessarily devastated innocent American lives and trillions of current and future wasted health care dollars (diverted away from medical care).”

    Ok, let me get this straight, saving millions of lives who would have most likely persished in other cultures that practice realistic and fair balance of options is doing this culture a favor? Saving smokers’ lives so they can smoke longer and have more disease for us all to pay for? Obese, inactive people can get back home to their couch and have the EMT crew bring in a crane to get them out the next 911 call comes?

    Get real! Social Darwinist here to remind you all, we die, it is painful to endure as a witness, and some people make bad choices and set bad goals and have the outcomes they have set for themselves. Asking the young to bear the burdens of decades of decadence and selfishness is not a solution, it is just a breeding ground for more resentment.

    You know, the campaign mantra for Obama and company!?

  12. PS- NO where (but here) is health care justice and equality considered a “radical” idea.

  13. I believe medical care for every American should be based on medical science, not what kind of coverage we have or lack. I also believe that if we were all united together into the same transparent, non-discriminatory, not-for-profit public plan, in the light of day we would save millions of unnecessarily devastated innocent American lives and trillions of current and future wasted health care dollars (diverted away from medical care). I would start by adding the president, his family and all government employees (that includes all congressional critters) into traditional Medicare so that a younger healthier risk pool would save the program for generations to come, then allow any other American who wanted to, to join without discrimination. Then we could sit back and watch how fast they made the program even better than it is already. Everyone in DC, plus everyone in the private health unsurance industry, plus anyone who has done their homework, knows that private health unsurance cannot begin to compete with a not-for-profit public plan on a level playing field. If I was President, I would ask my good buddies (Oprah, Tom, George, etc.) to help me explain the evidence, facts and truth to the American public. The concept is called healthcare justice and equality, and either we all have it or we all don’t. We all don’t, and won’t for the foreseeable future. Like slavery and women’s right to vote, ending our current legally condoned discrimination against old and sick people (that Obama’s health reform maintains), health care justice and equality is the single most important unsolved civil rights issue of our day. If healthcare reform was Civil Rights, Obama just handed the keys to the candy store over to the KKK. The irony is if we did (end the discrimination, injustice and inequality in medical care, that is), not only would we save millions of lives, but we would also save our economy.

  14. Yeah, I’m sure should representative Mcgovern and his minions should take away free speech to suit their personal needs, we’ll all thank his ilk for regressive tactics to just gag the masses.

    I’m glad you support this kind of thinking, per the way your comment above reads to me. Makes people like me wonder why you are so outraged when we call this partisan attack for what it is and then said supporters act so innocent and call us unfair.

    Welcome to projection as a juvenile defense, fellow readers!

    Hmm, June is coming, I guess the writing is on the walls of the Court?

    There will be no real winners in November, just millions of losers, those being the moderates and independents who almost outnumber the real losers of the extremist left and right , but their shout downs drown out healthy dialogue. Jeez, can’t the two sides of rigidity just find a room or field and have your battle royal and finish each other off!?

    Again, since day one here commenting, I hate the law, it is not going to sizeable help America, and there are no true supporters who are not first looking to how the Democrat party is affected by the ongoing progress, or to me regress, the law imparts on the country as it currently continues. Which is why I write as I do. And again,we need responsible legislation that political action per its part needs to provide to return some sanity to health care needs, not a smothering blanket that just furthers the financial agendas first, foremost, and completely.

  15. bspoon, I wonder if you hold the opinion that the rest of the world has single-payer health care and that’s what the US should have too?

  16. Why thank you for referring to me as a mindless minion. I’m sure you meant it in a respectful manner and will take it as such.

    As for George F. Will, he has a wonderful sense of humor. I almost always find his column good for a laugh and the one you linked to is no exception.

  17. There is NO way any liberal worth his salt should support this more-of-the-same-horribly-broken-status-quo piece of corporate welfare crapola health “reform” (NOT) bill. Expanding and enriching the most broken part is no solution. More of the same is not change, and more of the problem is a huge leap in the direction precisely opposite from the best, most honest solution. Regressives should be happy as larks while progressives should be holding their heads in their hands and asking WTF? Obama’s plan to reform health coverage for Americans under age 65 is the exact same as Romney’s Massachusetts plan, and Paul Ryan’s plan to “reform” Medicare for Americans age 65 and over (i.e. force everyone to have to purchase profit-driven, unreliable, over-priced, defective coverage from amoral, insatiably greedy private corporations…with NO right to join a not-for-profit public plan). Next we’ll be forced to have to purchase private retirement plans from Wall Street banksters instead of have any right to not-for-profit public Social Security. Sheesh. We’re being duped like we’ve never been duped before.

  18. Yeah, let’s all cheer for those wonderful liberals who want peace, harmony and exchange of dissenting dialogue.

    Maybe George Will’s opinion piece yesterday won’t thrill you, SteveH and your buddy Maggie M, but since you opened the door for me to share this link, I hope other readers who aren’t bound and gagged by the extremist lobbies at either end of the aisle of alleged representation in Washington will at least ponder what he wrote, about another “wonderful” liberal who is looking out for us. Yeah, if we embrace blue donkeys!!


    Second to last paragraph, tells you what liberals are really about.

    Oh, and again, I AM NOT A CONSERVATIVE! Enjoy washing off all that mud you try to throw at those of us who do not genuflect to you like mindless minions!

    Still wish there was a sarcastic font, so people can understand how dripping my comment was with the tone!

  19. “Flawed legislation. Does anybody dispute that?”

    I’m really not aware of any perfect legislation. Are you?

    “I am unsure that the insurance prouduct I buy on the exchange in Colorado is going to be available to me when I move to Iowa. Why not?”

    Because many people insist on having state-based control. You know, the local is better kind of thing. Personally, I agree with you but if there was only one, Federal Exchange, conservatives would insist that it was being imposed on States.

    “but why they structured it in an unconstitutional way instead of as a tax on all…”

    Functionally, it’s exactly the same as a tax, so what’s the problem?

    “I would have liked it better if those pushing for “reform” had demonstrated an understanding of what some of the alternatives were…”

    Many different ideas were explored, usually by looking at other countries health coverage systems to see how they worked. We ended up with a system that looks kind of like Switzerland’s which features private health insurance companies that compete for consumer’s business.

    “There are very good alternatives that have never seen the light of day because of this unquestioning support of the messiah’s health care bill.”

    Whoops. I thought I was responding to a rational person. My mistake.

  20. Thank you for the idea. I’m sure it occurred to you because that is exactly what you, as a conservative, would do if the circumstances were reversed. Unfortunately liberals actually believe that stuff we spout about respecting other people’s opinions and don’t plan to kill people just because they see differently than we do.

  21. Yes, he is (crazy or wrong or both), and this bill is the biggest piece of corporate welfare crapola ever passed over on a misinformed and unsuspecting public. It lets health unsurers charge three times more just due to age, for example (see page 44 of the “condensed” just under 1000 page version). Who can afford three times THESE rates? And who among us is most likely to actually need protection? And there is virtually NO punishment anywhere for the industry if it defies the law. I could go on and on, but that’s enough for now.

  22. “How can the government make us buy health insurance? What gives them that right?”

    “I like that it won’t let insurance companies deny care to people with pre-existing conditions.”

    Don’t you just love it. I guess we can make insurance companies provide us with insurance, but we can’t make people wanting insurance buy it – until they need it.

    And Republicans say “liberals” are financially irresponsible.

  23. Exactly the tone that makes these discussions so frustrating Not sure what the make up of congress has to do with anything and I’m no liberal or great fan of the Act. I value open and honest discussion though so if there is a legitimate point about the mandate creating an undue burden on physicians, love to hear your thoughts on it. It’s nothing that I’ve seen raised to this point. My only point is that I hate uninformed opinions from either side.

  24. And I’m offended when the criticisms are uniformly ingnored when trying to have a debate with a supporter. They assume that if you criticise the bill you are conservative and therefore unworthy of a reasoned response. They assume that because you criticise you do not agree with the positives and so in reply to the criticisms, all they do is repeat the positives, as if that will magically make the negatives go away. Well it doesn’t matter how much good the PPACA (excuse me – Patient Protection and Affordable Care Act) does, if we cannot survive or bear the negatives, then the positives are of no consequence.

  25. How many attorneys would appreciate mandated demands on their profession? Oh yeah, how many politicians were former attorneys, 75%?

    The mandate is not a tax, but, a burden that was never honestly debated.

    Oh, by the way, NOT a conservative.

  26. Nice analysis. This is the sort of dialogue that would help us find real solutions to real problems. I believe that some of the comments here are representative of the problem. The author is an undisputed expert but many of the commentators dismiss his points completely to simply repeat common conclusions with no rationale or analysis. As an attorney, and an educator on the US healthcare system, I’m offended when I hear “I”m a conservative, therefore, I’m against the PPACA (not that they actually know the name)” When asked what they know about it – they admit, only about as much as the pretty simplistic comments I see above.

  27. Flawed legislation. Does anybody dispute that? The question is whether or not it is fatally flawed. I really like the idea of exchanges – but I am unsure that the insurance prouduct I buy on the exchange in Colorado is going to be available to me when I move to Iowa. Why not? I think the broader idea behind the mandate is reasonable, but why they structured it in an unconstitutional way instead of as a tax on all with a credit for buying insurance is beyond me. It clearly is unconstitutional as written – very poorly done. I would like the law better if it contained true cost-saving measures. As it is it is way too expensive – to the point that it clearly threatens our future stability as a country. I would like it better if it recognized that there are segments of our population whom are better served by providing health care instead of by providing insurance. Giving them insurance will raise expenditures significantly.
    I would have liked it better if those pushing for “reform” had demonstrated an understanding of what some of the alternatives were – I appears that the ideas contained in PPACA were the only ideas that mattered to them, other than the “public option.” And it doesn’t help that the supporters of the legislation are so quick to brand opponents as racist or as in love with the current system. Their rabid attacks on those who dare question the glory of “the one true reform” is in and of itself reason enough to be against the PPACA. There are very good alternatives that have never seen the light of day because of this unquestioning support of the messiah’s health care bill.

  28. People who have sick children or spouses won’t be chained to their old jobs just because that’s the only way they can get coverage for their loved ones. They’ll be free to act on their dreams and start their own businesses to provide a better life for their families.

  29. How can they force people to buy insurance? If this was to happen the cost could increase for everyone as people in poor health would have to ake out insurance and then the claims would increase.

    This increases the cost for everone!

  30. If they can make you buy it then they can make you use it. If they can make you use it they can make it selective. If they can make it selective they can make it discriminatory. All on your dime!! WTF? Are you crazy?

  31. You know what, if you as democrat diehards are so worried your precious legislation is going to be killed by the judicial branch, which by our constitution is acting as arranged, then just put out a contract on one or more of Bush appointees and win by pure partisan behaviors! Jeez, partisan legislation by lawyers and businessmen masquerading as representative politicians does not deserve sympathy nor support from people it screws.

    Waiting for “The Pelican Brief” in reality!!!